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Provider Reimbursement Specialist

May 28, 2026

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.Applicants for this job have the flexibility to work remote from home and preferably reside in New York or within the tri-state area. Prefer candidates who are skilled with fee schedules and claims analysis. Position Purpose: Maintains relationships with physicians, hospitals, ancillary providers and Health Net's internal Provider Network Management Dept. Acts as first line contact for providers/hospitals on claims projects and other non-routine claim issues. Oversees, in conjunction with the Adjustment and New Day Unit Supervisors, resolution of project issues and is responsible to communicate final resolution to the provider/hospital or other business units and/or managers, as needed and/or as required. Assists with policy and procedure interpretation. Researches, analyzes and resolves complex problems with claims development and finalization.<ul><li>Assists with complex claim issues and acts as the first line contact for providers on large projects and non-routine claim issues</li><li>Manages projects in conjunction with assigned adjusters and/or regional units for research, analysis and resolution</li><li>Responds directly to the providers with final resolution of the issues, up to and including: root cause documentation/feedback, necessary corrective action plans and/or process improvement initiatives</li><li>Conducts routine periodic site visits to providers/physicians/facilities</li><li>Participates with Network Management in Joint Operating Committee (JOC’s).</li><li>Coordinates with Provider Network and Provider Data Management for contract data corrections</li><li>Identifies and reports to Provider Network Management contracting opportunities with problematic provider contracts based on root cause analysis</li><li>Interprets Health Net’s Policy and Procedures as it relates to claim issues, providing interpretation and clarification on contracts and benefits</li><li>Coordinates with Provider Network Management (PNM) if unable to resolve with provider and internal departments</li><li>Participates in process improvement activities working directly with the process improvement team to report root causes and facilitates corrective actions as needed</li><li>Prepares monthly reports to management to document issues, action plans, and resolutions of quality initiatives and provider relation improvement initiatives</li><li>Researches and responds to Shared Risk Discrepancies from Participating Provider Groups</li><li>Performs other duties as assigned</li><li>Complies with all policies and standards</li></ul>Education/Experience: Bachelor’s degree in Health Services, Health Care/Hospital Administration, a related field or any combination of education and/or work experience providing equivalent background required. Minimum of two years experience in medical claims review and/or claims appeal required.Pay Range: $56,200.00 - $101,000.00 per yearCentene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...

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